No matter the headlines about tax cuts, immigration controversies, or foreign threats, the top priority for Americans remains health care. People can’t get care when they need it and most struggle to afford health care costs, both insurance premiums and out-of-pocket copayments.

The latest so-called crisis in health care is about work requirements for Medicaid recipients. Supporters say these obligations are good for the health of enrollees. Detractors claim that work requirements violate the spirit and intent of Medicaid law.

Both sides avoid the real issue. As a physician I cannot ignore the real problem, which is this question: are Americans entitled or are they free? They can’t be both. Work requirements in Medicaid are not about money or health as much as they are about entitlements, personal responsibility, and the meaning of freedom.

Current Medicaid rules prohibit a state from placing any obligation on an enrollee other than qualifying under federally mandated eligibility standards. States are forbidden to require co-pays, to demand patient cost-sharing, to expect job training or job-seeking, or to insist on volunteer activities in order to obtain Medicaid health insurance. In other words, unless Washington waives its own rules, a state cannot introduce personal responsibility into its Medicaid program.

Ten states have recently submitted waiver requests to require some form of work. Kentucky’s waiver was just approved making it the first state to allow Medicaid work requirements.

Work requirements mean there is some measure of personal responsibility in Medicaid, which has always been a welfare entitlement. By contrast, Medicare is a program working people pay into throughout their careers. By doing so, Medicare recipients accept their responsibility for the payout they will eventually receive. Unlike Medicaid, Medicare enrollees paid for what they get.

Medicaid is a government handout with no pay-in by the recipient. Without the imposition of work requirements, Medicaid is a federal freebie devoid of personal responsibility by the recipient.

Should there be a component of personal responsibility in our health care system? Doctors would say that the person, not the doctor nor the government, is responsible for good health or bad. In fact, doctors agree that good health is only possible when the patient accepts that he or she, as a free person, is personally responsible for themselves, and acts accordingly. A patient who feels he has no “skin in the game” expects to eat without restraint, never exercise, and get a pill from the doctor to reduce weight.

The person who accepts entitlement expects the government to provide not only health care but good health itself. The government, not the patient, is responsible. The government, not the patient decides what health care will be provided and how healthy the patient is. The patient who rejects responsibility also rejects freedom.

Conversely, when one acknowledges freedom and accepts personal responsibility, the individual flourishes. He (or she) does for himself rather than waiting for the government to provide for him. There is great dignity and self-satisfaction in self-reliance. Furthermore, people who are personally responsible may be healthier. Healthier people are cheaper – they consume fewer health care resources.

All this is more than just political theory: it is an everyday reality. Americans believe they are free. They have the right as well as responsibility to choose for themselves. Yet, by invoking an entitlement to health care, 74.2 million Americans­ enrollees in Medicaid reject freedom of choice. They can no longer decide for themselves what care they get, or when, even if, they will get care. These Americans cannot decide how much, when, or even if, their care providers will be paid. Worst of all, entitled Americans, despite giving away freedom and giving away their medical decision-making authority to the government, still don’t receive the care they need when they need it.

Americans can either be entitled or they can be free. They can’t be both.